PRACTICAL GUIDE TO IMPLEMENTING ORDERCOMMS IN RADIOLOGY

Benefits of good Ordercomms Implementation in Radiology 1. Reduced radiology departmental administration time 2. No Lost requests 3. Improved patient care due to good & timely communication between Referrers & Radiology Department

There are 4 Clinical IT systems that are involved in Electronic Requesting in Radiology within Secondary Care: 1. Ordercomms 2. RIS (Radiology Information System) 3. PAS Usually within NHS Secondary Care, PAS usually provides the Patient Master Index of patient demographics (name, DOB, sex, address, PAS no., NHS number). PAS also holds the information where the patient is located & responsible consultant at a particular point of a clinical episode (i.e. ADT messages— Admission Discharge & Transfer 4. PACS Choice of IT Systems An organization may choose to all 4 IT systems from the same supplier. Alternatively, an organization may choose to a different supplier for each of the 4 above systems. However, the integration requirements need to be clearly defined for a successful implementation.

A. Ordercomms Data Fields Population (Secondary Care*) There are 4 methods of populating data fields on Ordercomms a. Search/choose from lists (see section, b. free text entry c. Automatic population from log-in details/system

The following data fields in to be populated & the information in brackets indicates best method of data population. 1. Patient Demographics (search from a database list which is synchronised with PAS Master List) a. Name, b. DOB, c. Sex, d. Address, e. PAS No., f. NHS No. 2. Requesting **Responsible Consultant/GP (automatic population from PAS—Responsible Consultant at Request—but can be changed by user if required) 3. Requesting Speciality/Department/GP surgery (Automatic population from PAS—based on what is chosen for point 2 above) 4. Requester (Automatic population from log-in details) a. Name b. Grade of Requester c. Contact number for Requester 5. Patient Location at Request (automatic population from PAS—Patient Location at Request but can be changed by user) 6. Date & time of Request (automatic population from system) 7. Priority---Urgent Routine (Choose from a list) 8. Patient Category---NHS, Private, CatII etc (Choose from a list or default based on patient location) 9. Exam Description---(choose from list—National Exam Codes & Descriptions) 10.Clinical History---Free text entry 11.Exam/Location/Gender specific Questions/Alerts (See Section I)

Notes: 1. *For Primary Care— a. PAS will be replaced by GP System b. Consultant will be replaced by GP

2. **Responsible Consultant concept–Within NHS secondary care Responsible Consultant is the named team leader who holds the overall medicolegal responsibility for a patient for an episode. Junior doctors & allied medical professionals usually working under their code. During any NHS admission/Clinic visit a patient will be allocated a responsible consultant within the ADT system or PAS. During a admission a patient may be transferred between more than 1 consultant but at any one time there is only 1 responsible consultant.

B. Ordercomms Data Fields that MUST be transmitted to RIS automatically: 1. Patient Demographics a. Name, b. DOB, c. Sex, d. Address, e. PAS No. f. NHS No. 2. Requesting Responsible Consultant/GP 3. Requesting Speciality/Department/GP Surgery 4. Requester a. Name, b. Grade & c. Contact no. 5. Patient Location at Request 6. Date& time of Request 7. Priority 8. Patient Category 9. Exam Description 10. Clinical History 11. Exam specific questions (See Section I)

C. Real time Exam Status Synchronization It is very important for a rich integration that all 3 systems--(Ordercomms, RIS & PACS)—are synchronised for the exam status: 1. Requested (ORDERCOMMS) 2. Request Vetted (RIS) 3. Request held/deferred—with reason (RIS) 4. Scheduled or appointment given (RIS) 5. *Cancelled (RIS/ORDERCOMMS) with reason 6. Arrived/Attended (RIS) 7. Did Not Attend (RIS) 8. Exam performed (RIS) 9. *Exam not performed—with reason (RIS) 10. Report Dictated (RIS) 11. Unauthorised report (RIS) 12. Authorised/Verified Report(RIS) 13. Amended Report (RIS) 14. Report acknowledged (ORDERCOMMS/RAS) 15. Review requested (Ordercomms)

*Cancelled—status is before the patient arrives in dept *Exam Not performed –status is after the patient arrives in dept.

D. Change and Cancel requests on Ordercomms Status synchronization between Ordercomms & RIS is key here. An Ordercomms system SHOULD ONLY ALLOW a user to cancel or change a request at the “REQUESTED” status (because until then the radiology department has not dealt with the request).

Once the RIS has taken the request and dealt with it with a status change to —“vetted”, held, “scheduled/appointment given”, “patient arrived/attended”—the Ordercomms SHOULD NOT allow a clinical user to cancel or Change a request. The following message should come up on the Ordercomms system---“this request is now with the radiology department---if you wish to change or cancel please ring extn----“.

E. Change and Cancel requests on RIS At vetting stage or later an order maybe cancelled on RIS. Through status synchronization the status in Ordercomms & RIS to cancelled. The reason for changing or cancelling the Request is documented in RIS. The reason for cancellation must populate the results field on Ordercomms. This will allow for appropriate communication to referring teams.

F. Patient Location on Ordercomms: It is important that the department understands that with electronic systems like Ordercomms term “location” is clearly understood on all the systems, OCS, RIS, PACS and PAS. 1. Patient Location at the time of Request. This is what is currently recorded on paper systems. This is where the reports currently goes to (as the responsible consultant for that request is at that location—and is responsible for reading the report). With Ordercomms deployment, paper requesting will continue for some time in tandem. Hence, it is important that consistency is maintained for both processes. This location is currently manually entered into RIS. It is important that when integration work is done, that the HL7 message populated into RIS from Ordercomms, is actually the “Patient Location at the time of Request”. 2. Current Patient Location: This is generally updated on an ADT (admission Discharge Transfer) system--- in the UK this is the PAS system. It is possible that a request for a scan is made when the patient was an inpatient, but at the time of appointment or reporting the patient maybe admitted to hospital as an emergency. Hence, it is important that staff in the department are aware of the current patient location to arrange porters/convey any critical report.(Please see E). 3. PC Location: Some Ordercomms may actually record PC location instead of patient location---as “location”. This is particularly of value for use of shared printers where request card/sample labels for pathology are being printed out. It is important to understand that PC location may not be synonymous with Patient location. Current paper based processes deal with “Patient Location at request” not requesting doctor’s location or PC location.

G. CONSISTENT CLINICAL USER INTERFACE RIS, PACS and Ordercomms MUST display clearly and consistently the following vital information. 1. Patient Demographics (Name, DOB, Sex, PAS No., NHS No., Address) 2. Current Patient Location 3. Current Responsible Consultant 4. Current Speciality or Department 5. Requesting Responsible Consultant (The difference from Requesting vs. Current Responsible Consultant & Requesting vs. Current Patient location must be understood) From a patient safety perspective it is recommended that the above 4 items are displayed on the top demographics bar of all systems. The above ( 1 to 4) MUST have real-time synchronization with PAS, so that it is always up-to-date. a. This will allow critical patient related information to be communicated with the correct team/doctor who is responsible for the patient by other departments. b. It also allows the departmental staff to know where patients are when an appointment has been made for them.

H. Electronic Request Information Display on RIS RIS must be able to display this information in a clearly which is easy to read by radiologists 1. Clinical History 2. Exam Description 3. Priority 4. Requesting Responsible Consultant/GP 5. Requesting Speciality/Department/GP surgery 6. Requester a. Name b. Grade c. Contact Number of Requester 7. Patient Location at Request 8. Patient Category 9. Date of Request 10. Output from Specific Questions based on exam type/location etc asked on Ordercomms (See Section I):

I. Exam/Location Specific Questions should be configurable for local needs. Some examples are: I. “Read by Referrer" Exams—For example plain X-ray requests for limbs post fracture manipulation, fluoroscopy images in theatre, OPT etc. (not for Chest/abdo/spine plain x-rays) will have the following question: 1. Report Required (Radiology) Is a report required? Yes or no II. Female and of child bearing age (for relevant exams only-All CT, MRI, Fluroscopy, some plain X-rays, NM etc): 1. Pregnancy (Radiology) Is the patient pregnant? Yes or No. If yes, EDD--- . For MRI exams the following message will appear: Please discuss the need for MRI with a radiologist. III. Inpatient/A&E Examinations a. Infection (Radiology) Does the patient suffer from infections which require barrier nursing: No, C.Diff, MRSA, b. Mobility (Radiology) Mobility---Chair/bed/trolley/Portable(if poss) IV. Outpatient Examinations a. Transport (Radiology) Transport---Own transport, Medicar, Ambulance V. Questions for Exams Requiring Iodinated IV Contrast (CT with contrast, Angio, IVU, etc): 1. Contrast Induced Nephropathy Risk Assessment (Radiology) “The last Creatinine level was ----- on --/--/--“ (This will be automatically displayed from the results/pathology system) Contrast Induced Nephropathy Risk Assessment based on recent Creatinine Levels (link to local guidelines) RCR Guidelines on IV contrast use: https://www.rcr.ac.uk/docs/radiology/pdf/BFCR(10)4_Stand_contrast.pdf Options to choose from: i. Low risk (Creatinine <130)---Peri-procedural oral fluid hydration advised. Patient Informed. ii. High Risk (Creatinine >130)---Need for IV contrast administration needs to be reassessed (e.g. Would a non- contrast exam suffice? Is an alternative investigation possible?) If IV contrast exam is deemed necessary, then peri-procedural IV fluids hydration as per guidelines needs to be organised by the referring team. iii. Not relevant—as patient is on dialysis iv. Up-to-date Creatinine levels requested

2. Diabetes (Radiology)--- (Iodinated contrast exams only –not MRI) Is the patient Diabetic? Yes or No a. If Yes---Is the patient on ----Diet control, Insulin, Metformin or medication other than Metformin? i. If on Metformin---Please read the RCR advice re: Metformin and IV contrast. RCR advice on IV contrast use: https://www.rcr.ac.uk/docs/radiology/pdf/BFCR(10)4_Stand_c ontrast.pdf a. If the serum Creatinine is normal, no special precaution is required. b. If Serum Creatinine is abnormal then the need for IV contrast should be reassessed ((e.g. Would a non-contrast exam suffice? Is an alternative investigation possible?). If IV contrast is deemed necessary, discussions with a Diabetologist is required before stopping Metformin.

VI. Questions for MRI Exams 1. Absolute contraindications to MRI (Radiology) Does the patient have any electro-magnetic implants (which are MRI Hazards) such as: Cardiac Pacemaker Cardiac Defibrillator Implant Cochlear Implants Brain/Nerve/Bladder Stimulator etc Answer: Yes, No, Patient not present If answer is Yes: Patient cannot have an MRI scan. Please discuss with radiologist regarding alternative test.

2. Possible Contraindication to MRI-- Safety Assessment Required (Radiology) Does the patient have any possible contraindications to MRI--- Intracranial aneurysmal clips Retained shrapnel Metallic Prosthesis Spinal rods Heart surgery Spinal surgery Brain Surgery Recent surgery Shunts/vascular stents/vascular clips Others Answer: Yes, No, Patient not present. If answer is yes : Please provide details with date and type of procedure/implant. MRI staff will do a safety assessment prior to MRI.

3. Metallic Intraorbital Foreign Body (MRI hazard) (Radiology) Does the patient have a any history of a metallic Intraorbital foreign body (Please take relevant occupational history—welder etc)? Answer: Yes, No, Patient not present If answer is Yes? MRI will pursue with patient to ensure safety as per Intraorbital Foreign Body Policy for MRI. 4. Claustrophobia (Radiology) Is the patient claustrophobic? Yes, No, Patient not present a. If yes, Do you think patient will require oral sedation or GA (they will need to choose 1 of the options). i. If they choose Oral Sedation then message will appear: MRI department will discuss with patient and organise for oral sedation. ii. If they choose GA then a message will appear: Please take relevant medical history and refer to Anaesthetic Dept for assessment. " 5. MRI Safety Questionnaire Reminder (Radiology): Please ensure that the patient fills in and signs the MRI safety questionnaire. If the patient is unable to fill in/sign off a safety questionnaire, it is the responsibility of the referring doctor to sign it on behalf of the patient. 6. Patient Girth & MRI (Radiology) (This will appear for all examinations) Please ensure that the patients maximum body circumference does not exceed 170cms otherwise the patient will not fit in the MRI scanner 7. Exam Specific Girth & MRI (Radiology) This will appear for certain exams like cervical spine/neck etc). Please ensure that the (body part requested - neck, knee, abdomen etc ) circumference does not exceed (measurement in cms ) otherwise the patient will not fit in the MRI (coil type e.g neck/ knee/ body phased array) coil. Max neck circumference = 45cm Max knee circumference = 60cms Max circumference for chest, pelvis, liver, MRCP, abdomen = 150cm 8. MRI Contrast (Gadolinium) (This will appear for all examinations that require Gadolinium) “The last Creatinine level was ----- on --/--/--“ (This will be automatically displayed from the results/pathology system) Please read Royal College of Radiologist guidance https://www.rcr.ac.uk/docs/radiology/pdf/BFCR(10)4_Stand_c ontrast.pdf on use of Gadolinium in patients who: a. Have impaired renal functions b. Are peri-operative liver transplant c. Are pregnant d. Breast Feeding

VII. Alert for exams requiring Bowel Prep (barium enema etc) Bowel Prep Alert (Radiology): NB: Please ensure that the patient can tolerate bowel prep. Guidelines link. VIII. Reminder for exams needing consent form: Consent Form Reminder (Radiology) NB: Please complete a consent form for this exam. IX. For any same exam requested within the last 6 months the following message will pop-up. Repeat Exam Alert (Radiology): This exam was performed/requested on DD/MM/YYYY" However, this should not prevent a further request being made, and should not require extra mouse clicks.

J. LINK TO DECISION SUPPORT FROM ROYAL COLLEGE OF RADIOLOGISTS: At every stage of requesting, the Ordercomms system should provide the url link to RCR decision support—“Making Best Use of Radiology Services” http://mbur.nhs.uk/index.asp

K. CONSISTENCY IN NAMING OF DATA FIELDS— There should be consistency in naming of the following data fields in Ordercomms, RIS, PAS & PACS (in fact in all Clinical IT systems). This would avoid ambiguity and confusion for the user community. 1. Requester 2. Grade of Requester 3. Requesting Responsible Consultant/GP 4. Current Responsible Consultant/GP 5. Patient Location at Request 6. Current Patient Location 7. Date of Request 8. Date of Exam* 9. Date of Report 10. Patient Category 11. Exam Description* 12. Exam Status* 13. Reporter 14. Grade of Reporter 15. Clinical History 16. Patient Location Types (Inpatient, Outpatients, GP etc) 17. Requesting Department 18. Reporting Department 19. Priority *Where there is a overlap of data field use in radiology & pathology—the term “Investigation” maybe more appropriate rather than “Exam”.

L. CONTEXT LINK: ORDERCOMMS, RIS & PACS: 1. RIS to Ordercomms: There should be a context link from RIS to Ordercomms, which will allow radiology staff to open Ordercomms to the relevant patient through a button/icon on the top tool bar of RIS. Thus radiology department staff will be able to: a. communicate with the referrer of any reasons of cancellation—using electronic Mail (preferred methodology is to communicate reasons for change or cancellation via reason populating the report screen—Item N) b. document on Ordercomms notepad (if available) any information for any Clinical user to see. c. allow radiology staff to review blood results with ease—Creatinine levels for contrast exams etc d. Use Ordercomms messaging between clinical requesters and reporters—this may help to provide feedback to reporters—re: post-op outcome etc, and also allow for requesters to request a second opinion from a radiologist. 2. Ordercomms to PACS: There should also be a context link from Ordercomms to PACS a. At patient level on Ordercomms to patient level PACS Imaging history—to prevent unnecessary duplication of exams b. At Exam/Report Level (after the status is updated to exam performed or later) on Ordercomms to specific exam on PACS

M. PAPERLESS RADIOLOGY DEPARTMENT: It is possible to have an Paperless radiology dept but the key issues to tackle: 1. RADIOGRAPHERS PCs---Adequate number of PCs in radiographer modality areas is crucial. 2. MISSING ORDERS---Good Regular housekeeping by admin staff in radiology to ensure that Orders do not go missing. 3. ELECTRONIC VETTING---RIS electronic vetting module is required. It should be easier to vet electronically—than current paper processes. Radiologists must be able to change and cancel requests on RIS, which will feed back to Ordercomms—with reason for cancellation (see issue N). At the time of vetting, radiologists should also be able to include protocols, sequences, comments etc which should easily & automatically visible to radiographers & appointments staff. 4. RIS & ORDERCOMMS CONTEXT LINK: There should be a CONTEXT LINK between RIS and Ordercomms, which will allow radiology staff to open Ordercomms to the relevant patient through a button/icon on the top tool bar of RIS.

N. ORDER OUTCOMES on RIS & COMMUNICATION Every order MUST only have one of the following outcome status on RIS 1. Cancelled in RIS 2. Did Not Attend (DNA) 3. Exam not Performed 4. Authorised/Verified Report Each of these outcomes MUST be communicated with the requesting team. The reason for “exam not performed” and “cancelled” must populate the report text of the results screen.

DNA, cancellation of order on RIS, exam not performed reason should not require other forms of communication (letter/telephone etc). The form of communication must be the consistent with what is used for communicating a approved/verified report.

A RIS may communicate verified reports with other systems electronically which may include 1. Ordercomms 2. Results Acknowledgement System 3. PACS 4. GP systems etc The “results” sent out from RIS should include the following: a. Cancelled in RIS with reason b. Did Not Attend (DNA) c. Exam not Performed with reason d. Authorised/Verified Report

O. REQUESTING a SECOND OPINION The aim of the Project to implement Ordercomms should be to improve communications between requesters and reporters by using a electronic requesting. Whilst most Ordercomms are able to make a primary electronic request for an exam, there is also a need for systems to enable a request for a second opinion. Royal College of Radiologist recognises the importance of recording of second opinions

P. TABLES/ MASTER LIST CONCEPT: When buying a Ordercomms it is important to ask suppliers tables/lists for the following entities. 1. Patient list (with demographics—name, age, sex, address, PAS no, NHS no) 2. Responsible Consultant/GP List 3. Department/Speciality List 4. Patient Location List 5. Requester List (name & grade) 6. Reporter List (name & grade) 7. Exam Description or code 8. Exam Status List

PAS should hold the master list for 1. Patient List (demographics—name, age, sex, address, PAS no, NHS no) 2. Responsible Consultant/GP List 3. Department/Speciality List 4. Patient Location List

RIS should hold the master list 1. Exam Description or code (National codes usually) 2. Exam Status List

Hospital IT Directory of users (LDAP) should hold a master list of all hospital staff with grades. 1. subgroup of this list will form the Requester List in Ordercomms (based on the grade of the staff). 2. Another subgroup of this will form the Reporter List in RIS (based on the grade of staff)

If the Ordercomms solution holds a separate table or list for the above entities, then it is important that these automatically synchronise with master lists for these entities. NB: If there is no automatic synchronization between these lists with the master lists, there will be a lot of time consuming housekeeping due to duplicate entries into the different systems

Q. PRIMARY CARE ORDERCOMMS: The above document largely deals with implementing an Ordercomms in a secondary care environment. If electronic requests are made in Primary care, the HL7 messages from a Primary care Ordercomms (Section A) should flow into the Secondary Care Ordercomms (and then from secondary Ordercomms to RIS, Path etc)

R. ORDERCOMMS HOUSEKEEPING

Tables & Master list is key to understanding housekeeping for Ordercomms. Messages will go from a GP Ordercomms to a secondary care Ordercomms. Then from Secondary Ordercomms to RIS GP Orders Housekeeping 1. GP Patient not existing on PAS-- GP system holds a patient master list for GP patients PAS holds a Patient Master List of Hospital Patient (with demographics—name, age, sex, address, PAS no, NHS no) If an Order is made for a patient on GP system, but the patient does not exist on PAS, these orders will not proceed to RIS until these are sorted, and a Hospital PAS entry is created for that patient. The Secondary Care Ordercomms should hold these in a separate list— Deferred/Pending Orders Worklist for housekeeping purposes. Once sorted these orders should move automatically to RIS. 2. All Responsible GPs within the Surgery & GP requesters must be present On the Secondary Care Ordercomms. If there is a list mismatch (Section P) then a Order will not proceed to RIS and will move the Deferred/Pending Orders List. 3. There maybe a mis-match of address between PAS & GP system which will need sorting out before a GP request can be processed.

Secondary care Orders Housekeeping 1. If the following lists must be synchronised between PAS, RIS & Ordercomms (Section P) i. Patient list (with demographics—name, age, sex, address, PAS no, NHS no) ii. Responsible Consultant/GP List iii. Department/Speciality List iv. Patient Location List v. Requester List (name & grade) vi. Reporter List (name & grade) vii. Exam Description or code viii. Exam Status List If an order has an message element which exist on a list in Ordercomms but does not exist on RIS, the Order will not proceed on RIS (Example a new location or new consultant has been created and put into the Ordercomms list but not on the RIS list). These should move to a Deferred/Pending Order on RIS for housekeeping. Hence, it is important that these lists are kept automatically synchronised by both RIS & Ordercomms suppliers. 2.There maybe a failure of the interface between Ordercomms & RIS when Orders will not proceed to RIS. There must be a mechanism to alert the Systems Manager when the interface has failed.

S. VETTING ON RIS Once an Ordercomms is implemented paper request cards should slowly disappear. The RIS must be able to perform the vetting functions adequately. 1. Change/Cancel Orders---At vetting stage an order maybe cancelled on RIS. Through status synchronization the status in Ordercomms & RIS to cancelled. The reason for changing or cancelling the Request is documented in RIS. The reason for cancellation must populate the results field on Ordercomms. This will allow for appropriate communication to referring teams. 2. Protocols & Sequences---Currently radiologists use the paper to scribble protocols & sequences on the paper card at the time of vetting or protocolling prior to scan list. These cards which is subsequently available to radiographers at time of scan. It is important that RIS has the functionality to record any protocols or sequences and make this available throughout the workflow in the department in the same way as paper based workflow. 3. Vetting Worklist: The RIS supplier must provide a flexible approach for radiologists/radiographers/other staff to create vetting worklists (based on modality, Referring department/Speciality, Responsible Consultant etc).

Above document compiled by Dr. Neelam Dugar following discussions on various threads of The UK PACS and Teleradiology website with contributions from many of its members.

Dr. Neelam Dugar Consultant Radiologist Doncaster & Bassetlaw Hospitals NHS Trust Chairman of The UK PACS & Teleradiology Group 14/9/10